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HELPING FOSTER CARERS TO MANAGE CHALLENGING BEHAVIOUR

HELPING FOSTER CARERS TO MANAGE CHALLENGING BEHAVIOUR Evaluation of a cognitive-behavioural training programme for foster carers

by Geraldine Macdonald Ioannis Kakavelakis University of Bristol Prepared for The Centre for Evidence-Based Social Services, Peninsula Medical School, University of Exeter, 2004 FOREWORD People less straightforwardly committed to the idea of evidence-based practice in social work than the present company, often baulk at its supposed obsession with randomized controlled trials (RCTs) and the difficulty in carrying them out in a complex field such as ours. There are three points to make in this connection:

(a) there is no such ide -among the people that we in the Centre for Evidence- Based Social Services collaborate with, only a determination s to assess findings according to the bias-reducing properties of, and the representativeness of, the study in question;, but they are as rare

(b) trials are indeed not the only fruit, but they are as rare asas blue oranges in our field and so this concern amounts almost to self-delusion; (c) there is no reason why qualitative t material (often uncritically prized for its nice name) cannot. be included in trials as they are in this excellent report. This is a This is a study about foster carers, the essential, frontline troops of the child care system, and is concerned with the question as to whether research-based training could make a difference to outcomes for children. Thus it could not be -more central. This is especially the case now that face- to-face support for them is diminishing so that more vital work on records, statistical returns and target attainment checklists carries off 80% of the working week of social workers, leaving foster carers somewhat isolated with the increasingly demanding children who now come into care. The trainThe training project featured in this study has easily best outcome-research record in the field of psycho-social interventions, but has been tried out only to a limited extent with very up-against-it children in care. Therefore, CEBSS decided to commission an RCT. Two of the five hypotheses were confirmed, but then this is not the issue. Studies containing negative findings are equally precious in that they tell us of further work that needs doing - in this case to support foster carers doing a very difficult job in less than supportive circumstances. The qualitative sectors of the trial show how grateful were the carers for the training and support they received as part of this experiment, and they provide us with much practical advice, as to the best way to improve services. The authors The authors are to be congratulated on pulling off a first class project; for achieving the highest standards of methodological rigour, but above all, for achieving this in very complex circumstances. This report should thus be read by all in the. child care field from service heads to frontline staff. Salut. Salut. Professor Brian Sheldon

Professor Brian Sheldon Director Centre for Evidence-Based Social Services

Contents

List of fi gures and tables......................................vi Acknowledgements.............................................vii Executive Summary.............................................. INTRODUCTION.......................................................12

MANAGING CHALLENGING BEHAVIOUR.......................73

THE TRAINING PROGRAMME....................................174 METHODOLOGY......................................................235 RESULTS...............................................................316

FOSTER CARERS USE OF BEHAVIOURAL METHODS....517

F0STER CARER SATISFACTION.................................678 DISCUSSION.........................................................719 CONCLUSIONS.......................................................79 REFERENCES........................................................81

Appendix 1: The Knowledge of Behavioral Principles As Applied to Children (KBPAC)...................85

Appendix 2: The Course Task........................................86List of figures and tables FIGURES 4.1 Recruitment and allocation of foster carers......................25 7.1 Satisfaction with the programme....................................68 7.2 Improvements in problems that promoted participation in the course............................................................68 TABLES 1.1 Children looked after at 31 March 1997-2001, with three or more placements during the year..................................2 2.1 Studies of the effectiveness of foster carer training programmes............................................................11 3.1 Outline of training programme.......................................20 5.1 Summary of Mann-Witney test results on fostering experience...............................................................33 5.2 Number of children fostered across time period for training versus control groups....................................34 5.3 Between-group comparisons relating to number of fostered children at different time periods....................34 5.4 Repeated measures analysis of variance of scores on the KBPAC scale...................................................35 5.5 Means of KBPAC scores.................................................35 5.6 Results of Chi Square and Fishers Exact Test (FET) for behavioural strategies used by foster carers at Time 1 (pre-training).................................................37 5.7 Results of Chi Square and Fishers Exact Test (FET) for behavioural strategies used by foster carers at Time 2 (post-training)..........................................................38 5.8 Results of Chi Square and Fishers Exact Test (FET) for behavioural strategies used by foster carers at Time 3 ( 6 month follow-up).................................................39 5.9 Number of unplanned placement breakdowns across time periods for training versus control groups.....................40 5.10 Between-group comparisons for the number of unplanned placement breakdowns at different time periods...........41 5.11 Months at risk across time period for training versus control groups................................................41 5.12 Training group versus control over three time periods.......41 5.13 Proportion of perceived difficult behaviours across time periods for training versus control groups.....................42 5.14 Between-group comparisons relating to proportion of perceived difficult behaviours at different time periods...43 5.15 Means of Internalising Scores........................................45 5.16 Means of Externalising Scores........................................45 5.17 Means of Total Scores...................................................46 7.1 Views on the level of difficulty presented by various teaching methods..........................................69 7.2 Perceived usefulness of teaching and learning methods.....70 viiiixExecutive Summary

1. Introduction (Chapter1)1.1. Children looked after have consistently fared less well than others on a range of indicators, including health, education, and social adjustment. One of the factors which increases childrens risk of adverse outcomes is lack of placement stability. Unplanned terminations of placements and frequent changes of carers can undermine childrens capacity to develop meaningful attachments, disrupt friendships, and contribute to discontinuities in education and health.

1.2 Children looked after have long been recognised as experiencing high rates of behavioural and emotional problems. Among the many reasons why behaviour problems matter is that they are strongly correlated with unplanned placement endings.1.3 Previous research has also highlighted the need for foster carers to be better equipped to manage the range of demands placed on them by children with emotional and behavioural problems.

1.4 1.4 This study was designed to test whether training foster carers in methods designed to help them manage challenging behaviour would be helpful to them and benefi cial for looked-after children. Whilst primarily concerned to test whether it enabled carers better to manage diffi cult behaviour, we were also interested in whether it would enhance carers confi dence in their capacity to care for challenging children and young people and, ultimately, whether improved skills and/or confi dence would enhance placement stability.2. Managing Challenging Behaviour (Chapter 2)1.1 Cognitive-behavioural training was chosen on the basis of its track record of effectiveness in dealing with a wide range of emotional and behavioural programmes; its effectiveness in training birth parents (i.e. parent training), and evidence from some previous studies of training foster carers xxi1.2 Typically, a cognitive-behavioural approach aims to help participants to develop i) an understanding of the ways in which behaviour can be shaped by the environment, ii) skills in analysing behaviour commonly referred to as the ABC of behaviour1, iii) selecting strategies to change the relationship between behaviour and its consequences and/or changing the antecedents (e.g. asking a child to get ready for bed after making it clear what his/her bedtime is and turning the television off before asking), and iv) monitoring and reviewing progress.1.3 The study tested six hypotheses. These were as follows:1.4 (i) Participants in the training programme condition would score signifi cantly higher on the Knowledge of Behavioural Principles as Applied to Children (KBPAC) scale than foster carers in the wait-list control condition. (ii) Participants in the training programme would be signifi cantly more likely than foster carers in the wait-list control group to use behavioural techniques in managing childrens behaviour.

(iii) For children in the experimental group2 there would be fewer unplanned terminations of placement in which behaviour problems were implicated.

(iv) Participants in the training programme would report a signifi cant reduction in the range of problems that they found particularly diffi cult or challenging, compared with foster carers in the wait-list control.

(v) Foster carers in the training programme would report success in dealing with behaviour problems.

(vi) Foster carers would feel more confi dent in their abilities to manage diffi cult behaviour.

2. The Training Programme (Chapter 3)

Where A represents antecedents, B represents behaviour and C represents consequences.

1.1. The content of the training programme developed for this study mirrored that of programmes that have proved effective when provided to groups of parents facing diffi culties with their children. More specifi cally it was based on an established programme developed by Herbert and Wookey (In press) for use with birth parents.

1.2. The training sought to familiarise carers with social ilearning theory, both in terms of understanding how behaviour develops and how it can be infl uenced using interventions derived from social learning theory. There was an emphasis throughout on developing the skills to observe, describe and analyse behaviour in behavioural terms the so-called ABC analysis. 1.3. The programme gave due consideration to the fostering context, and to the particular constraints and pressures under which carers operate. 1.4. The programme was designed to promote a sense of confi dence or self-effi cacy. Self-effi cacy has been shown to be correlated with effectiveness.1.5. The programme was originally designed as fi ve weekly, three-hour sessions plus a follow-up session and this format was used for the fi rst two groups. Because these groups felt rather pressured, we decided to move to four weekly, fi ve-hour sessions plus a follow up for the remaining four groups. The content of the programme remained unchanged. 1.6. Each participant foster carer was provided with a Course Handbook. This contained details of each of the sessions and information relevant to each. It was written and presented in what we hoped would be an easily accessible format. Participants were asked to read certain sections between sessions as part of their homework, and had an opportunity to discuss the material at the beginning of each session.1.7. The training was organised to refl ect a collaborative approach to problem-solving, such as that described by Herbert and Webster-Stratton (Webster-Stratton 1998; Herbert and Webster Stratton 1994). The training was designed to marry the expertise and experience of foster carers with the specialist knowledge of the trainers and their experience of tackling child behaviour problems. 1.8. Two trainers ran the training programme: The lead trainer was a clinical psychologist who was experienced in working with troubled and troublesome children and young people. The other was a professor of social work who had a special interest in behaviour problems and looked after children. 1.9. grant holder. To minimise bias, all data were collected and analysed independently by a researcher recruited specifi cally to the project. Ixiii3. Methodology (Chapter 4)

4.1 The most secure way of answering questions about the effectiveness of a particular intervention is by means of an experimental research design. The most common design is a randomised controlled trial, in which research participants are randomly allocated either to receive the intervention or to a group that does not. The latter is referred to as a control group.

4.2 This was the design used in this study. Carers who agreed to participate in the study were randomly assigned either to the training group (the experimental group) or a wait-list control. Those in the control group continued to receive standard services and were told that should the training prove helpful, it would be made available to them in the future. The funders of the research Directors of the South West Consortium gave this undertaking. 4.3 The participants in this study were foster carers in six local authorities in the South West of England.

4.4 Although we initially received statements of interest from a large number of carers, this number dwindled for a variety of reasons. In addition to those who did not meet our inclusion criteria, some withdrew from the study once the dates and/or location of the training were confi rmed. Others withdrew when told they had been allocated to the control group.

4.5 Final numbers of willing participants allowed us randomly to allocate them to the two conditions, but we had to do so on a 1 in 2 basis (rather than the 1 in 4 that we had intended), and we had to do so within geographical regions. This effectively means that we ran three small trials, rather than one.

4.6 The outcome measures used were:

(i) A measure of participants knowledge of behavioural prin...

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